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HomeMy WebLinkAbout0025 MILNE ROAD - Health 25 'Miine Road Osterville P .� ..t• - a' S. < U ,% .X ,.:r'i:; .:rr `� Y �f ^fix. )t - '„�, 4 l _ i6 s .r� 'K a .i - r •:. d ^ G r :, t.1''ts. r.� -,'r- ..: • '•..,"ar :. �� '.•. '- :: =.p , , '" ..:�s '. ''"{f c d�' �i u. r.:��• :d F r �::�`� a t `3,': far .. a r } i 7 .. � ... t. .:'y ..,. '^' :..s"" _�•,: .:' �•;;•;i•: .:yxaN,¢�•.�� ..;� ++fix; .. 4 4' ;' -t 'M z�.. a+' 1 �". p :rA. } a..� ' - �nh � its ,S-a. t9,:". F �'t. '',<•i': ''d 4r`'. `'S�F et ..� ;is�• >:� n. ,p � � " 1t .. ssT)s. $„ 't. ! F'R� •°`-" .d'.., AY: Y) ' J ,t , ,. i' !,� T �a ,'♦J S �.V ,.W f - : a r e i e • w A . .. - '.,,, h ••. - . , "„d;.. r4, ,- x! '.`Y>�,. cf 'm - k; fix, � .,, t .s`� ... .fi .1� t -'• •- jm .. * � �r x.t , 4� tr r. r�• i3 "` t, r1 ',,� ;n. n,' :t<•t •+} "^' .,, - �'p ram.t, ..J ;rx c},. 'i.._ �'i: }...,N '' 4 ._.;„ . :• .r a G .. d t ri C1 � S", � . to e. PI r, : G' Y t , � D Li . i, a�i• p 4 . r n i . e ,a "` � -''� ,.ut. ,� n ',..; to '. 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R } � ..• .. r i � _, ",c _ -, .. r _ „ V � - 'y. { �_ - 1 •s;�' loll ' cc , c r r _ a + r n J k iT' i t4 + rr a a ;v r 7, { op • y vY „ x , C' u + i 4 � , ,r ire� •�� : ���3 : �. fi; WR.n � o bin _ NB'T41IC S1�p 101 D�stanoe edn t r' amiim, s C �m�awble tQ theBottn 6f ltgFty �rsvatc�ita�erSv101 malt end ng�a t!► E�€ Edgenftetad�uigq'1fY wstlmd eras, y ant 386'6eet Ieacag ) Ped I C Qu J � CN caw � ` Commonwealth of Massachusetts ._ '� +.., ��_�,-r,, .�:� -: :�►. r Fora . f ,� Tile 5 Official . I nspectionf form. 1.1 Subsurface Sewage Disposal System Form:Not for Voluntary,Assessments r �:M ,-4 25 Milne Rd :. 'r Property Address ;a John Troppmann rr ^z •t�<t' ,•h•.t, fir# Owner Owner's Name •, i information is r , required for every Osteryille P ,:4.; MA 02655 2-15-21 t a page. City/Town , , State Zip Code Date of Inspection .4 Inspection results must be submitted on this form. Inspection forms may not be altered"inn any way. Please see completeness checklist at the end of the form. l +..a' .,r.+ I t Ar _ ti('.Y�N'1• r•.I �; it�`i4- !. •} ,.� *• A. Inspector Information �'l,► ,.r,�i8'-�. .,� Shawn Mcelroy t,, ,-•. r:''. Name of Inspector r. 'Upper Cape Septic'Services ?"`` :ry'.: Company Name P.O. Box 73 Company Address East Falmouth :�' r, + MA, [x, +/a+y :'­ :02536 City/Town State Zip Code 508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 15.000);I have personally inspected the sewage disposal�system at'ttieproperty address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on"my fraining andfexperience in the proper function and maintenance of on-site sewage disposal systems'After conducting this inspection I have determined that the system:. 3. t ,, r.,. ; ,_ 1. ® Passes".:t + 2. ❑ Conditionally!asses.i2 � + +c+ t i s, tt t • `: r ',: ii' lt.;Iv`f1 ul ;i•' :' t'rj ;at. r� .- •. r 1 e r' -,,.r i '•yr1 , . r , ' 3. El Needs,Further Evaluation by the Local Approving,Authority.- 4. ❑ Fails G!e 41, t :if et ;{i. iPft:` {t '^P,1 ;( a 2-15-21 - Inspector's Signature ^ "' �` `" Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. - Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev:7/26/2018 r. n Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 - Commonwealth of Massachusetts 1.; Title 5 Official Ins pec$ion-;Form, w� hY Subsurface Sewage Disposal System Form-Not for Voluntary'Assessments > ;a r ,� 3 r f�; 25 Milne Rd Property Address John Troppmann f Owner Owner's Name information is , required for eve osterville : MA 02655 2-15-21 q every City/Town/Town'• State Zip Code Date of Inspection page. Y p p C. Inspection Summary • ,. r t, ••a t ? 'r .,dts .fw.. A It ��, _ S •` .r i`-f�F r. • !.�" , ..,."y" � 14 Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. ` 1) System Passes:r ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criterianot evaluated are indicated below. Comments: System is in good working order with no sign of failure. F d •i a! '1_'� r 'f r•f,i•} .. . I Ir r - r� r t', ' 2) ,System Conditionally Passes: t'. - t_ - .• -.�. •. Y _ i,7-}. .. sri �- !• a .. " . ' ... * ,9 . "` I 1. I, . # , i I .; .I , •• ❑ One or"more,system components as described in.the "Conditional Pass' section need to be 4 I , replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following,statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether'metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. r *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ ND (Explain below): t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 i� i Commonwealth of Massachusetts J . 11 Title 5 Official I nspectioh Ford{ i t Subsurface Sewage.Disposal Systernform -Not for,Voluntary;Assessments . . j.r 25 Milne Rd - Property Address John Troppmann r .�1r}fa .l lrlc Owner Owner's Name ,+a n••, information is ,- required for every Osterville MA 02655 2-15-21. , y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ., 2) System Conditionally Passes,(cont.): , , ,• £t ,?Vtrrt. •() N'-ttr : • � , � ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if I pumps/alarms are iepaired. • ' ' ' r ' ,X`•°' '' ' j r• .r. . ,�. ..,4�' S 1• .'i� LiT {.`_ � 1i•�„e,, •nrf *"4 rlij t f#: t :fly ❑ Observation of sewage backup or-break out or high,static water level in the distribution box due to broken or obstructed pipes) or due to a broken, settled or uneven distribution box. System will ` ' = pass inspection if(with'approval of Board of Health): -Li' - . ' ?'; ... ' - • � 1� , 1� tri'�6� s,�c. rz i. It'! {:� rt ��' t';. -'"� '❑-`''-w broken pipe(s)'are replaced -'.J❑aYcF❑N't'Y❑4ND•(Explain below): .. t_ obstruction is removed �`�` £�� ❑ 'Y ❑N`"40, ND (Explain below): "' ❑' ' distribution box is leveled,or replaced--',T❑Y- ❑"N"'•'❑' ND (Explain below): !S^ • Pfrn '*aft. ! ,�3't'1-i..! t rt 1 I Y. t . t, ! rn t, t. :,yi. •S: +n,iC {,• t .c ?" t ❑ The system required pumping more than 4 times a year due to broken:or.obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below): ❑ obstruction is removed ❑Y - ❑N ❑ ND (Explain below): 3) Further Evaluation is Required-by the.Board of,Health:-;, -j!'- c ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system'is failing to protect public health, safety or the envir6nment:'-1 a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: �` " ' ` 4 t"•+' Jilt 'L v ri:t v I °;tj' t5insp.doc•rev.712 612 01 8. ,. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 ,. Commonwealth of Massachusetts = r ,'. Title 5 Official Inspection Foie Y_ dab Subsurface Sewage Disposal System Form -Not•for Voluntary Assessments J_ >' 25 Milne Rd Property Address John Troppmann Owner Owner's Name information is Osterville MA 02655 2-15-21 required for every `a' ' page. City/Town State Zip Code Date of Inspection j C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface•water ❑T Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh . , b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, s safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and.the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. --❑The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. -- ❑The system has aseptic tank and,SAS and.the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. t, c' Other: i 4) System Failure Criteria'Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: x Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of-effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts < =:1..��r; .. r . ;,r� ` 1 +.,-, �� ,,::— , ip Tile 5 Official� Inspection rm'� C�'1 Subsurface Sewage Disposal S stem Form.-.:,Not for.Voluntary,Assessments,--j-,�,, t+ s 25 Milne Rd �►r f'fr;r ? Property Address John Troppmann n!I,rx;rxhi i -h , Owner Owner's Name �,:e >.+•,,, information is Osterville r ,''' MA 02655 -, n required for every ` page. City/Town ! State Zip Code Date of Inspection C. Inspection Summary (cont.) r-. , � :r: - a .,; 3 , ,i zf 4).,System.Failure,Criteria Applicable to All Systems: (c(?nt.) „ , +Jig ,, ., .tit. ' . 1 !. t,c. "�' 't� ,n•lr ...'74. !rJ°�• . i 1,yfi�,::,���•�I'� �: ,�� lii�t-. : ._� "' '`;-i'{ ii' '�+ I:.i,a ,Ye$•t.�t ;Nt)elii{ r#:7f 117i�i^" �:.�•iYt}i'.r4;. fT1:3°s'< 'ii�lfi"�`l� ter �l.!'7� i tr i .s jf'• . t}}'Static liquid"level in'the distnbution'boz above'oiitlet inveri'due to an overloaded or clogged SAS or cesspool' ''r"" '�' ' �' r Liquid depth in cesspool is less than 6" below.invvert or available volume is less r c << ' "than''/z'd8y flow' "'0 3 .rs �:, .:ty� r ® Required pumping more than 4 times in the last year NOT due to clogged or El obstructed pipe(s). Number of times pumped: "'=' r 1: . ".:e ,w , t, ❑ ��,.+®!,� r ;Any portion of the SAS, cesspool,or,privy is below high'ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or ❑ ® ''`tributary to a'Surface water supply.' Any portion of a cesspool or privy is within a Zone 1 of a-public water supply f• ❑ . ®c �r4s well.", t*:�i`} /k.`.�t +'.. -•1 . u .fi}t ! x ' r '" ❑'` '�® b'. Any portiori'of a'cesspool or privy is within 50 feet of a private water supply well. „oft t3,",ss I-I I f 1ii f., t! nt_, .4�ar.. ; *'a•r'Y 3fr.:•fn roa _•'t "4,jet 4j. 4,� It+ - ❑ ® Any portion°of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well`wifli no acceptable water quality analysis. [This system passes if;the,well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal Wor less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody,must,be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000 gpd- . .' E,.Il {'a ..r F JN: 4L .��''�- "7' r 1 10,000 gpd.V ' Y� tr<'+, fk) - r r1 r f• -;.a v- The system fails I have determined that one or more of the above failure 01'' '®I ''''criteria exist as described'in 310 CMR`15.303,therefore the system fails. The ,system ownerishould contact the Board of Health to determine what will be _i y %rnecessary to correct,the failure.-(,,,r.. - h Sidi r ye,: thi+ 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000`gpd to 15,000 gpd.' zrfrT-�r . 1 ; r' _-For large systems,you must indicate either"yes"F or,"no'to,each of the following, in addition to the questions in Section C:4.: Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev:7/28/2018.„, f y Ar_ , , - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 A " :,� Commonwealth of Massachusetts i Title 5 Official Inspection Form i Subsurface Sewage'Disposal System Form,- Not for.Voluntary Assessments 25 Milne Rd Property Address John Troppmann Owner Owner's Name information is Osterville MA 02655 2-15-21 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) _ a a If you have answered "yes"to any question in'Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. • 4 ' 6. You must indicate "yes" or"no"for each,of,the following for all inspections: Yes No > ❑ ,F ® ;'Pumping information was provided by the owner, occupant, or Board of Health ❑ ® L Were anyof the system components pumped out in the previous two weeks? ' 1. , ',• . t ❑ ® Has the system received normal flowsin the previous two week period? ❑ - ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® 0 Were as built plans of the system obtained and examined? (If they were not available note as N/A). ` f '® ❑ " Was the"facility or dwelling inspected for signs of sewage back up? " e ® t, Del Was the site inspected for signs'of break out? ®-• 1 ❑ '-Were all system components;excluding the SAS, located on site? r ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank ,inspected.for,the condition of the baffles or tees, material of construction, .dimensions, depth of liquid, depth of sludge and depth of scum? ' 1 Wasthe facility owner(and occupants if different from owner) provided with ® El information on'the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example,-a plan at the Board of.Health. Determined in the field•(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7t26t2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 `� •. Commonwealth of Massachusetts �. Title 5 Official, Inspection. Foft m Subsurface Sewage Disposal System-Form -Not for:Voluntary.Assessments..4ht'K- ; 25 Milne Rd Property Address John Troppmann Owner Owner's Name r;-;t f• , , ,.� information is 7 -t required for every Ostervitle. MA 02655 2-15-21 page. City/Town State Zip Code Date of Inspection D. System Information - - 1. Residential Flow Conditions: ;�„-,• . ,;r , ��= ri --?;, r,.;;,� mr.- � Number of bedrooms (design): 1 Number of bedrooms (actual): 1 DESIGN flowbased on 310 CMR 15.203 (for,example: 110 gpd.x#of bedrooms): 110 Description: . .t) .'` :���:iZ�'C•�'.l•-tS.tf°�H�y iv +ls f? Yi��. f}.'f•.,.+.^•.+'� Number of current residents: p f 1 'or 0 Does residence have a garbage grinder?�,r -,t, ; r_L,,sf* e t Jt,f'.� ,';4rj El Yes ® No Does residence have a watertreatment unit? �r{� ;,;_ �, +'a ,t .;;µ x ❑ Yes ® No If yes, discharges to: ,L,, I.j±x, _ , , , Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) "'"' ' ,r °' ` �' Laundry system inspected? - ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: �L•l°t . +� - - - -- �t� >,�++.. :-�' rlr 1.k:�. V�.'rfi�°`t "- a�>� .f,`,��• II Sump pump? � r +. ^:n,>A .0; ❑ Yes ® No Last date of occupancy:- t ,_ s„ . . Unknown ri��'� G. �l s ".+t Date t5insp.doc•rev.7/26/2018. , = c.. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts ' �- ,. Title 5 Official Inspection Forte rp Subsurface Sewage Disposal System Form -Not for Voluntary Assessments " r ,:a• r r 25 Milne Rd Property Address John Troppmann r Owner Owner's Name information is osterville .' 'r' MA 02655 2-15-21 required for every ' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: 'Type of Establishment: Design flow(based on 310 CMR 15.203): ' Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? u ' ❑ Yes ❑ No Water meter readings, if available: r ' Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts ;_:a�,,' ,r� Yc „�� .•r . . . 1 f Tile O��iciaBInspec$!on Form", ' r�► Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r Property Address John Troppmann t ,ioi Owner Owner's Name . information is Osterville - . ., MA 02655 2-15-21 required for every page. City/Town .- State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ;;f_< ;`'�;;f. . •� P t .:,� ,E- r Septic tank, distribution box, soil absorption system , ❑ Single cesspool El., t 1r. .Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest .inspection of the I/A system by system operator:under,contract; t ❑,,. , ,Tight tank.Attach a.copy,of,the•DER approval. ❑ Other(describe): n,-. Approximate age of all components,date installed (if,,known) and source of information: 2009 Were sewage odors detected when arriving at the,site?f!tts 1';, ,I it, I p ❑ Yes ® No 5. Building Sewer(locate,on,site;plan) 4.,r,,: �,; jj; G.- ►, rtra It -;.., _; ,f �, 24" Depth below•g'rade: i4 "..• �" . f !, .! .` ,vp.1 ... .e.',l.` a�{:t'Sf, •.� ,{..;,i� ' tr).f Material of construction: ® cast iron ® 40 PVCr'r` �}'° ❑ other(explain),'' Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.7/26/2018. - Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 18 s Commonwealth of Massachusetts Title 5 Official Inspection _dorm w p Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments A 25 Milne Rd ' Property Address John Troppmann Owner Owner's Name Information is required for every Osterville MA 02655 2-15-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): - 18" Depth below grade: i feet Material of construction: > ® concrete ❑ metal ❑ fiberglass'' ❑ polyethylene ❑ other(explain) If tank is metal, list age: j ' years Is age confirmed by a Certificate of Compliance? (attach,a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" 6" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle •1511 , How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and,no sign of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts .,y:, r,;, . . ;•o ,L, :t� j:n;a„n;. r� 4. Title 5 Or icial{ I nspec$ion-F-oen „p Subsurface Sewage:Disposal System Form.-Not for Voluntary.Assessments-• 25 Milne Rd = Property Address „ John Troppmann -r. -; -- i Owner Owner's Name information is MA 02655 2-15-21- required for every Cisterville ;?3, 1•' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: . ;1 feet-,'';, 'I If,, "a Material of,construction: ❑ concrete ❑ metal ❑ fiberglass f ❑,polyethylene,, ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping:. '.F: . ,;,.n„ -)F,1; ;;r+ J,4, Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,'evideride of leakag6',1etc.):' ` ' � °.4 c:° `' 4 ' , `• .. ( nt' .0 I%•1 4• ' - -.r pJF.,.f+, tl`:-?.. �. •: d"3 'N-,� i.v.t( �: ".a.1,: It r"t l� ,s .�, r.j lil.. ../ X- a_FW:�fTt t.l rt et(}, rr. i`:r+I et :;t[ f *"f' +7 lF t= t*•' �t falr•'� a;ar+- !irk 8. Tight or Holding Tank (tank must be pumped at time of i nspecti on)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 r+ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official snspectiom-fdrm I4 r�i Subsurface Sewage Disposal System Form=Not for Voluntary Assessments +P r� < 25 Milne Rd Property Address John Troppmann Owner Owner's Name information is osterville = t 2 required for every MA 02655 2-15- 1 1 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) - Alarm present:. ❑ Yes ❑ No - ' Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached?-'' ❑ Yes ❑ No 9. Distribution'Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. J.. t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 r Commonwealth of Massachusetts ; F w Title 5 Official Inspection' Form', r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ; • +,r 25 Milne Rd h t r Property Address John Troppmann Owner Owner's Name information is MA 02655ill tOserve 2-15-21•n tom' required for every h � • page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): , ;f< ,c n 4, , 1K,a x, L Pumps in working order:' ,�M�. :� sty.° �.,,.� , ta, "r!s :�} -,.,� ❑`Yes ❑ No* Alarms in working'order:'.; ry,w .rf f-.�, t�T,.j t _r,. t y tip.,+ '.' '.' °�' ❑ Yes ' ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order,system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan,-excavation not required)!is(.- If SAS not located, explain why: ,,,t,- ;;�.� ►,, ,; 4 i Type: .❑ leaching pits ' �-. i,, :=r:� ,.. r..�number`or.) ' • A , tt). ® leaching chambers number: 2-13'x25'x2' ❑ leaching galleries number: - ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018. - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts 1- - ���. Title 5 Official, Inspection Fotm' p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Milne Rd Property Address John Troppmann Owner Owner's Name information is required for every ostefville `• MA 02655 2-15-21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) t: 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level,of.pond ing, damp soil, condition of vegetation, etc.): Leach chambers were empty at inspection with no visible stain lines. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth=top of liquid,to,iniet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 6 Official Inspecton Form:Subsurface Sewage Disposal System•Page 14 of 18 r Commonwealth of Massachusetts ,. �' ,: �- t,. , Title 5 Official Inspection- Form, iA p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Milne Rd Property Address , t,A, -. ;•.; John Troppmann ;, , ,,1lY,. .T •�+., Owner Owner's Name ; information is required for every Ostervtlle MA 02655 2-15-21• .': page. City/Town State Zip Code Date of Inspection ` D. System Information (cont.) �,��,, #�, _ w f l 13. Privy (locate on site plan): =r' -t ti�" '"� w� "t• _ ' ,'. r :u''f . t' •t'..+ , i ., .}. }I' 4r` if1'111 1`,1' Jam. #4- Materi6ls of construatiom' +TTat. Dimensions Depth of solids ' ' `' .fit, i T Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 3 w f. 1 • a t5insp.doc•rev.7Y2612018 w Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18. "° Commonwealth of Massachusetts Title 5 Official Inspectio' Form, 41 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments° `,ti`'! 25 Milne Rd Property Address , John Troppmann Owner Owner's Name information is required for every Osterville MA 02655 2-15-21 page. City/Town - State Zip Code Date of Inspection D. System Information (cont.) " 14. Sketch Of Sewage Disposal System: ; Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: • r ® hand-sketch in the area below ❑ drawing attached separately 3 k. ............. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18' I Commonwealth of Massachusetts . '�< F►_�r►w ,Yr ;:� x"r��a ► , � < , f Title 5 Official. I nspe boon {: o-mi; cal Subsurface Sewage Disposal System,Form :Not forrVoluntary AssessmentS0.)a.r r _n 25 Milne Rd Property Address 10 r,; John Troppmann Owner Owner's Name • , „„O + information is required for every Osterville , A .. MA 02655 2-15-21,- ,i,r " page. Cityrrown State Zip Code Date of Inspection D. System Information (cont ) ;'-3, 15. Site Exam: +.,,r':11,i * 03 t;14�Y.) t °31aigt cw ❑ Check Slope sr ,�A i „ �i ;q, t:r" ❑ Surface water sr S ,•. _ t -, Y ❑ Check cellar ❑ Shallow wells �, �3'•�)7;: 'e-y Estimated depth to high groundwater-:,)) 12'+,r.,;� 1,3 ;t s taf; : {r feet• "' x' = 1' Please indicate all methods used to'determine the high groundwater,elevation: ® Obtained from system,design plans on.record),1 �•i• ,.,If checked, date of,design plan reviewed-,, ® . ,.Observed site (abutting property/observation hole;within 150feet�of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 _ rr ��� .. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18. K 15e Commonwealth of Massachusetts - Tile 5 Official Inspection, Form rar Subsurface Sewage Disposal System Form -Not for-Voluntary Assessments tl J_ ti1>° 25 Milne Rd Property Address John Troppmann Owner Owner's Name information is required for every Osterville MA 02655 2-15-21' page. City/Town ` State Zip Code Date of Inspection E. Report Completeness Checklists a -4 Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16'or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN'OF BARNSTABLE LOCATION :L,S` �`' SEWAGE# s ,-VILLAGE ,� ( ASSESSOR'S MAP&PARCEL f 0 -0f INSTALLER'S NAME&PHONE NO. �G i�liJo6✓ 'l � � �� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) L Z (size)/ 3' ';t"r NO.OF BEDROOMS p OWNER PERMIT DATE: 2l/#i COMPLIANCE DATE: 7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility,---- Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland'and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY W 7M -t ' S J Qi r ` ;q� s 4 a y TOWN OF BARNSTABLE LOCATIONCZ SEWAGE # VILL kGE ASSESSOR'S MAP IO - bn L613 INSTALLER'S NAME&PHONE NO. l0,SEPTIC TANK CAPACITY ^^ LEACHING FACILITY: (type) (size) �(d6 nl NO. OF BEDROOMS_ BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i �� II �� �� • �� `�o . , A �, . .; ., L0CL,T1 0t,,J ' SEWO.C,E PERMIT MO. VILLAGE 11�lSTQLLER S IJ�tJIE � ADDRESS BUILDER 5 Q &V AE ADDRESS DNTE PERMIT ISSUED 0 ATE COMPLI &DICE ISSUED : l=mac C i `g r r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage disposal-System Form -Not for Voiuniary Assessments 25 Milne Road Property Address Ernest& Marie Jaxtimer a� Owner Owner's Name information is required for every Osteryille Ma 02655 4/11/2019 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. �� 74 Beldan Lane Company Address Centerville Ma 02632 Cityrrown State Zip Code e 508-658-3456, 774-248-4850 SI 4522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 4/11/2019 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate reaional.office.of.the:DEP..The.original.form.should.be sent-to-the,system..owner.and-copies.sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form e W— v Subsurface Sewage Disposal System Form-Not for Voluntary Assessments W� 14 25 Milne Road Property Address Ernest& Marie Jaxtimer Owner Owner's Name information is required for every Osterville Ma 02655 4/11/2019 page. Citylrown State Zip Code Date of Inspection C. inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 25 Milne Rd Osterville is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 2 precast leaching chambers. The system was found to be in proper.working condition at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.-The system; upon completion of the replacement-or repair;as approved_by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health... *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 25 Milne Road Property Address Ernest& Marie Jaxtimer Owner Owner's Name information is required for every Osterville Ma 02655 4/11/2019 page. City/Town State Zip Code Date of Inspection C. inspection Summary (cont) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: U VVI IUitions exist-VVlllldl C ulrC fuftlh CVQluation by the Board oil Health iii older-Uo d etCrl'1'1111 C I the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System'Form -riot for'voiuntary Assessments 25 Milne Road Property Address Ernest& Marie Jaxtimer Owner Owner's Name information is Osterville Ma 02655 4/11/2019 required for every page. Cityfrown State Zip Code Date of Inspection C. inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning_ in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. i ne system has a septic tank and SAS and the SAS is less than f u`u feet but 5G feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts 9 ,lp Title 5 Official Inspection Form vr.�. <!o' subsurface sewage Disposall system form -Not for voluntary Assessments 25 Milne Road Property Address Ernest& Marie Jaxtimer Owner Owner's Name information is required for every Osterville Ma 02655 4/11/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® �Liquiddepth in cesspool is less than 6" below invert or available volume is less than '/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspooi'or privy is within a Zone 1`oT a puoiic water suppiy well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory-,.for fecal califormbacteria indicates absent,a_nd the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone Il of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for voiuntary Assessments -�y 25 Milne Road Property Address Ernest&Marie Jaxtimer Owner Owner's Name information is required for every Osterville Ma 02655 4/11/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] - t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage'DisposalrSystem Form =Not for voluntary IAssessments a 25 Milne Road Property Address Ernest& Marie Jaxtimer Owner Owner's Name information is required for every Osterville Ma 02655 4/11/2019 page. City/Town State Zip Code Date of Inspection D. System information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110 gpd Desc ipuol on.. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Fls)' Subsurface Sewage Disposal"System Form -N01 Tor Voluntary Assessments 25 Milne Road Property Address Ernest& Marie Jaxtimer Owner Owners Name information is required for every Osterville Ma 02655 4/11/2019 page. Cityrrown State Zip Code Date of Inspection D. System inTormation (cone.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form la) Subsurface Sewage Disposal'System corm -NOT Tor Voiuntary Assessments 25 Milne Road Property Address Ernest& Marie Jaxtimer Owner Owner's Name information is required for every Osterville Ma 02655 4/11/2019 page. City/Town State Zip Code Date of Inspection D. System information (cone:) 4. Type.of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained-from system owner) and a copy of l6test.'."" inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: system installed 2009 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 1'5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leaks or blockages. Vented through roof t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Fora < Subsurface Sewage Disposal System Form Not for voiun ary Assessments 25 Milne Road Property Address Ernest& Marie Jaxtimer Owner Owner's Name information is required for every Osterville Ma 02655 4/11/2019 page. Cityrrown State Zip Code Date of Inspection D. System information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? openea QUver's a o EUUK measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form J1111111j Subsurface Sewage Disposai'System Form -`Not for Voluntary'Assessments -�" 25 Milne Road Property Address Ernest& Marie Jaxtimer Owner Owner's Name information is required for every Osterville Ma 02655 4/11/2019 page. City town State Zip Code Date of Inspection u: System information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official,, Inspection Form !off bubsuriace Sewage Disposal ys tem Form --Not for voiUntary Assessments 25 Milne Road Property Address Ernest& Marie Jaxtimer Owner Owner's Name information is required for every Osterville Ma 02655 4/11/2019 page. Cityrrown State Zip Code Date of Inspection U. System information (cont) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - ivot for.voiuntary Assessments 25 Milne Road Property Address Ernest& Marie Jaxtimer Owner Owners Name information is required for every Osterville Ma 02655 . 4/11/2019 page. Cityrrown State Zip Code Date of Inspection D.. System information (cont.j 10.. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2x500 gals ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �o! Subsurface Sewage Disposal System 'Form -Not for voiuniary Assessments 25 Milne Road Property Address Ernest& Marie Jaxtimer Owner Owner's Name information is required for every Osterville Ma 02655 4/11/2019 page. City/Town State Zip Code Date of Inspection D. system information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): leaching facility was video inspected and was found dry with no stain lines indicating that there has never been standing water. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposai"System Form -F. for'voiun tar y Assessments 25 Milne Road Property Address Ernest& Marie Jaxtimer Owner Owners Name information is Osterville Ma 02655 4/11/2019 required for every page. Cityrrown State Zip Code Date of Inspection D. System information (cont) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form !� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Milne Road Property Address Ernest& Marie Jaxtimer Owner Owner's Name information is required for every Osterville Ma 02655 4/11/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately ;�eA•2 2 � I 31b f 39 6 A4 Z 33 Z Zo /k 3 qO r r3 3 39 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form poi Subsurface Sewage Disposai'System Form riot for voiuntary Assessments 25 Milne Road Property Address Ernest& Marie Jaxtimer Owner Owner's Name information is required for every Osterville Ma 02655 4/11/2019 page. City/Town State Zip Code Date of Inspection D. System information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 124 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts MP fr� Title 5OfficialInspection Form � Subsurface Sewage Disposal'System Form-ivot'for Vo untary Assessments 25 Milne Road Property Address Ernest& Marie Jaxtimer Owner Owner's Name information is required for every Osterville Ma 02655 4/11/2019 page. Cityrrown State Zip Code Date of Inspection E. Kepon Completeness CheCKIISt Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete.all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached. For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 fo � Commonwealth of Massachusetts 617 Q� W 9 Title 5 Official Ins Fo rm Inspection o � ��. Subsurface Sewage Disposal System Form - Not for Voluntary Assessme 25 Milne Road - Property Address " David Hetherman lip Owner Owner's Name 01 information is psterville 0 required for every :� MA 02655 July 2, 2014 page. City/Town State Zip Code Date of Inspection -Mµy, ni Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, i use only the tab 1. Inspector: �7 key to move your c/I cursor-do not David B. Mason use the return key. Name of Inspector i David B. Mason Q Company Name 4 Glacier Path Company Address East Sandwich MA 02537 CityrTown State Zip Code 508-367-1617 S1287 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority v. July 2, 2015 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M °V 25 Milne Road Property Address David Hetherman Owner Owner's Name information is Osterville MA 02655 Jul 2, 2014 required for every y page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The observations noted in this report represent the condition of the system only on this date of inspection and the information contained herein does not guarantee the continued operation of the system. Change or increase in use may result in hydraulic failure. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts UW.. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Milne Road Property Address David Hetherman Owner Owner's Name information is Osterville MA 02655 Jul 2, 2014 required for every Y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 P Y Y �M 25 Milne Road Property Address David Hetherman Owner Owner's Name information is Osterville MA 02655 Jul 2, 2014 required for every y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Milne Road Property Address David Hetherman Owner Owner's Name information is Osterville MA 02655 Jul 2, 2014 required for every Y page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Milne Road Property Address David Hetherman Owner Owner's Name information is Osterville MA 02655 Jul 2, 2014 required for every Y page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 1 Number of bedrooms (actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 25 Milne Road Property Address David Hetherman Owner Owner's Name information is Osterville MA 02655 Jul 2 2014 required for every Y page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gP ))� Detail: 2013; 4000 gallons and 2015; 5,000 gallons. Sump pump? El Yes 0 No Last date of occupancy: UnknownDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: See Above t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M °V 25 Milne Road Property Address David Hetherman Owner Owner's Name information is Osterville MA 02655 Jul 2, 2014 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: — Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 c Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 25 Milne Road Property Address David Hetherman Owner Owner's Name information is Osterville MA 02655 Jul 2, 2014 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2009 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Typical Sludge depth: 3" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Milne Road M Property Address David-Hetherman _ Owner Owner's Name information is Osterville MA 02655 Jul 2, 2014 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 47 Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 3 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Scour Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Effluent level with outlet invert. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Milne Road Property Address David Hetherman Owner Owner's Name information is Osterville MA 02655 Jul 2, 2014 required for every page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): s Dimens io n : Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 25 Milne Road _ Property Address David Hetherman Owner Owner's Name information is u Osterville MA 02655 July 2, 2014 required for every _ Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert effluent level with outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): No evidence of solids carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 25 Milne Road Property Address David Hetherman Owner Owner's Name information is Osterville MA 02655 Jul 2, 2014 required for every Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: — Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 2-500 gallon precast chambers with 4 feet of stone. No ponding or signs of hydraulic failure noted. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Milne Road Property Address David Hetherman Owner Owner's Name information is Osterville MA 02655 Jul 2, 2014 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 25 Milne Road Property Address David Hetherman Owner Owner's Name information is Osterville MA 02655 Jul 2, 2014 required for every _—y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 25 Milne Road Property Address David Hetherman Owner Owner's Name information is Osterville MA 02655 Jul 2, 2014 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 18'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Groundwater Contour Map ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater Contour Map Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts L W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 25 Milne Road Property Address David Hetherman Owner Owner's Name information is Osterville MA 02655 Jul 2, 2014 required for every Y page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Assessing As-Built Cards Page 1 of 2 I TOWN OF BARNSTABLE LOCATION f S Iti,1AIr SEWAGE II VILLAGE `f'2frYLf ASSESSOR'S MAP&PARCEL �_. t'd/7 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Xr O LEACHING FACILITY:(type) L_c,— (size)%3 NO.OF BEDROOMS OWNER PERMIT DATE: 7y COMPLIANCE DATE:_?�/` j Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility.. Feet Private Water Supply Well and Leaching Facility(If any wells exist on. site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY http://town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=118017&seq=2 7/9/2015 j Town of Barnstable _ P#-1241,5 Departmnent of Regulatory` Services • STARL& r ;Public Health Division s g:e IDy Date 200 Main Street,Hyannis MA 02601 Date Scheduled _ ' Time L+T"t ' Fee Pd. _. —' `t . . Soil Suitability A sessment for Sewage isposal Performed By ����i G� I� ~ �c7�►fti 41mt WY, _` Witnessed By: LOCATION&GENERAL INFORMATION �" a Location Address i2 J MI LN E Name s Owner' - D9 V l L) .' . sT E iZV 1 L.L: t Add'SS D � { � _ �. _ ZS M l� �c. _ Assessor sMap/Parcel / ( / Engineer's Name ti NEW CONSTRUCTION REPAIR Telephone# . 0 c6 { �g T C7 Land Use KL'S 1d N ► I Slopes Surface Stones _ Distances from Open Water Body^(Op f . ft Possible Wet Area (�0 _ ft Drinking Water Well. ft.. L i fI ' Drainage Way �7 0�..F �p.r,. 1 _ } g_ y ft Property Line ft 'Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes) 73 i GROUNDWATER ADJUSTMENT rJ 0- EXISTING GROUNDWATER LEVEL n®® BAS ©eON TOWN .OF BARNSTABLE l 0 GIS DEPARTMENT-RECORDS. },. INDICATED GW 7.00 ` INDEX WELL M1W-29 j ZONE C READING\ DATE-MAY. 2009 READING 'r 7.4 ADJUSTMENT 2.3 ADJUSTED GW 9.3 C Parent material(geologic) s0 I�'.C(q.l DV De V10 Yl pth to Bedrock Depth to Groundwater. Standing Water in Hole: D 'e Weeping from Pit Face Estimated Seasonal High Groundwater 7L C' q bo y P _ DETERMINATION FOR SEASONAL.HIGH WATER TABLE Method Used:S e c c ©y e Depth Observed standing in obs.hole: In, .Depth to soil mottles; Depth to weeping from,side of obs..hole: in, Groundwater Adjustment ft. a Index Well# __Reading Date: ,Index:Well level %,Adj;factor AdJr(3rnurrdwttter l eVel -- �. PERCOLATION TEST . bate tvC.3cfoq'1'itnall AM Observation Hole# Time ut 9" !�1 Depth'of Perc C7 D't V► - Time at 6 �y r r Start, re-soak Time @ 10 ' S 3 Time(9"-61.) �1 End Pre-soak to �� F• Rate MinJInch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be'Completed oii Back------------ ***If percolation test is to be conducted within 100' of wetland,you must first notify the.. Barnstable Conservation Division at least one (1) week prior to beginning. Q:\SFPTIC\PERCFORM.DOC _ DATE OF TEST: JUNE 30. 2009 { '' SOIL TES T-- L,n.r WITNESDSEDI BYVALUATOR: DAVID SDAVIDDTAN ON.. HEALTH#461 DEPT. PERC NUMBER: 12615NO NCOUNTERED i I TEST PIT- I PAARENTU MATERIAL: PROGLAC AL OUTWASH PERC AT 60 in - 2 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING 35.60. 0-5, Ap LOAMY SAND 10 YR 3/3 NONE FRIABLE 33.63 6-26 B ' -LOAMY SAND - - _ 10 YR 4/4- NONE LOOSE - - 26-132 - C MEDIUM SAND. _ _ _ _ 10 YR 5/4- NONE LOOSE I 24.80 NO GROUNDWATER ENCOUNTERED-t:-!-, - + TEST PIT 2 PARENT MATERIAL:- PROGLACIAL OUTWASH -- s 2 MIN/INCH IN C SOILS ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER _36.20 (INCHES) HORIZON TEXTURE (MUNSELL) _ MOTTLING k 0-8 _Ap LOAMY SAND 10 YR 3/3_ NONE FRIABLE 8-30 B } LOAMY SAND _ 10 YR 4/4 NONE ~ LOOSE + 33.63 _ 30-126 C } MEDIUM SAND— 10 YR 6%4_ NONE s LOOSE 24.80 DEEP OBSERVATION HOLE LOG dole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%GrayeI a . Flood Insurance Rate Man: - Above 500 year flood boundary No— Yes Within 500 year boundary. No�� Yes - +� 'Within 100 year flood boundary No ✓ Yes Depth of Naturally Occurrine Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? ' Certification Q 9� I certify that on (date)I have passed the soil evaluator examination approved by the , Department of Environmental Protection and that the above analysis.was performed by me consistent with . the required training,expertise Jand experience described in 510 CMR`15.017. Signature® (S19 . Date lvne �� W01 Q:VSEPTIC\PERCFORM.DOC -,020 No. oo Fee IF I Co. •� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:—� PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ppfitation for bisposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair O� Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location tA�ddreses o otNo Owner's e dd e s PjC�and Tel.No. g- Assessor's Map/Parcel $ t-A%`n2 ko a-C-1 cos*_X V i K— Installer's Nacr�e�A dress,and Tel.No58=P �P Designer's Name,Address,and Tel.No.SO'1•3 424-oVil Type of Building: Dwelling No.of Bedrooms �'�'"-' Lot Size d 7 0 sq.ft. Garbage.Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3-30 gpd Design flow provided ? 3 y gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs o``rAlterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. y Signed '" i Date Application Approved by ~� ` - Date 7-7-0 q Application Disapproved by Date for the following reasons Permit No. 2 Fy -9,01 Date Issued ? ' 7 0 '•'^'^ ^--;• �• .... _ ^'�' ... � .�, ..n .. _..•. .'.,�n.-se �,',.._.�-...�;.•�.,.«ry.y�r..w•.n' °" ":-a,j:'�'ui`""`�f:`sr„''w".i;.�.'""'-'y�`y':... "'.+A•, , .. ,� . � , No. 6O I ' O I Fee l Qo. T ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: � PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpliratiott for BiSpoBal 6pstent Construction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components - Location Address or-Lot No. i Owner's Name,Address,and Tel.No.50 � "(00 A Lessor's Map/Parcel „ I-1 p1 t, Y�� Est 6)54e_-V, ! Installer's Name,Address,and Tel.No "73 5- Designer's Name,Address,and Tel.No.5O SG"-3 wnn F_ d-w suv\ NCO a>( to C`C;_.,I 4E-,r- J, 11 e, A i"�C i l�u-ct>E C; f<-I E, sa"-Cs W►C k,, Type of Building: Dwelling No.of Bedrooms Lot Size ad 700 sq.ft. Garbage Grinder i Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ?j 3 O gpd Design flow provided 3 3 y gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil ti I Nature of Repairs otrAlterations(Answer when applicable)__T_04jka� 0__ N 42s O cJ .�J�l.s""` 'tL3 Q 1t�.1(�S G�'1,,4 LwC7•- 1 Ee-C� = �-t, �'� ~1 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of i Compliance has been issued by this Board of Health. I Signed � - (// Date 2?-o Z�� �1 Application Approved by -�� Date 7-7-O � Application Disapproved by Date for the following reasons Permit No. a O -O�0 Date Issued 7 - 7`0 --------------- THE COMMONWEALTH OF MASSACHUSETTS �., �. BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by �r"' - 6�6\6%,(v�tN% 'S at 195 0S4-e,C t 1� '�.. has been constructed in accordance p� with the provisions of Title 5 and the for Disposal System Construction Permit No.02001-00 dated -7 -7- / Installer Designer #bedrooms Approved design flow —7 V ------------ . gpd The issuance of this permit shall not be construed as a guarantee that the system will-fu tion as designed. Date / / `�10 Inspector k) /"i'�VL✓• ---- --- -- ------ - ---------- - - ------- --- ------- -- ----------------- No. ,? - 0 09— ;� 0 Fee THE COMMONWEALTH OF MASSACHUSETTS t�Y PUBLIC HEALTH DIVISION BARNSTABLE,MASSACHUSETTS misposal bpstent Construction i9ermit Permission is hereby granted to Construct( ) Repair(X) Upgrade( ) Abandon( ) System located at 25 r( ,e)P_ C,4 • Q S 'J 1 ,ke. and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit.�^' 0c Date d Approved by -down of Barnstable oFE.,e,��o > :Regulatory.Services : . Thomas F.-Geiler,Director . * �anxsrast�: . " Pubhc Health Division 39. QED MA'S R Thomas McKean,_Director ._ ZOO Main_Street,Hyannis;lVlA Q2601 Offxce:.:508=862-4644 Fax: 508-790=6304.::.:. Installer:&::Designer:Certification Form Date: V Sewage Permit# a'�' Assessor's MaplParcel 1 Designer: C© -� Installer15LTnf i Address: C �'� c.@ Address:- C'� w�c utY. On : 1�f``� -�c�� �0� _,., was issued a permit to uistall a (date) (installer) - septic system design:drawn:b__ (address)_: Cam: E dated (designer) I certify that-the septic:_system:referenc above was=installed substantially according to the design; which may.include minor approved changes ouch as lateral relocation of he distribution-box and/or septic tank:_: I certify that the septic.-system_referenced.above was-installed with major changes (i e :......:.greater than-_10' laterd.relocahon=:of:the SAS:.or:any vertical relocation of any,component of the septic em but in accordance with State&Iocal Re ations -=Plan=revisia or ... ), gam.. . certified as-built by designer to.follow. N OF MgsS� r G� DAV1D cy COUGHANOWR allei s ignatureY : No. 1093 o ---- _ ST @1. SgN1TAO (Designer's Signature)- (Affix Designer's Stamp Here) • PLEASE RETURN TO :.BARNSTABLE PUBLIC- :.HEALTH -DIVISION: IFI CERTCATE :OF COMPLIANCE WILL NOT-BE ISSUED UNM BOTH THIS-FORM AND AS-BUILT CARD-ARE:::::::::::: RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION...THANK YOU. Q:Health/Septic/Designer Certification Form 3-26-04.4doc No..............L.,..... FuI,.J.- v........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF... CLC�........................... Appliration -for Biopoiial Vorkfi Tonotrurtion PPrntit Application is hereby made for a Permit to Construct ( ) or Repair (KI an Individual Sewage Disposal System at: -------_•............... ---------••---------'-- -------------------------------------------------------------------------------•--.........._---- Lo tion)ddress or Lo No. ..... W1 pk� - Owner / .C6�� Ad�tress. Installer Address Q Type of Building Size Lot-----------------------------Sq. feet U Dwelling—No. of Bedrooms------------------------------------__......Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) QOther fixtures ....................................................................................................... W Design Flow............................................gallons per person per day. Total daily flow......................._....................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width................. Diameter......---------- Depth................ x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area--__----__________sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY......................................................................... Date---------------------------------- Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water---__-__-__-______-__--" (14 Test Pit No. 2................minutes per inch Depth of Test Pit___________-________ Depth to ground water_-_-_--__-___-____-_-- V ..-- -----------....................................................................................................................................-- GDescription of Soil----�-�- ---V� ----------- --------------------------------------------_____--------------------------------------------------------------- x V -------- --------------- -------- -------------------------------------------------------------------- ....... ---------------------------------------------------------------------------------------------------------------- V Nature of Repairs or Alterations—Answer when applicable......_---------------------------_------------------------------------------------------------- --------------------------------------------- --------------------------------------------------------------------------------------- -----------------------------------------------------------------. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has Issued by the board f ealth. ---- ------ ------- ---------- �j D e Application Approved BY r '- --4 Date Application Disapproved for the following reasons:---•-------------•-----------------•-•----------------•-----•----•-----•-------_ .............................. ...................................................... -------••.__.....--------__.__--.--_._..___--_.------------------__...•----•----------------------------------------•----------------------_---•- Date PermitNo......................................................... Issued........................................................ Date • �.��. ��...�.. ------------------------ -- --- -07 `� �'<: No .�....--. _.......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH >� F>. oF... at -:.:<�':<' ::/�f-Via........................... ApVfirtt#tun -fur Uhipuotti Works Toni#rur#tun Vrrmi# Application is hereby made for a Permit to Construct ( ) or Repair (✓) an Individual Sewage Disposal System at: ---------------------------------------------•-•--------•-------------------------------------- f{ Location-Address or Lot"No. 0. ------- ----------------- ----------•••-••.-•... ...-- ...............................................................f j� V Owner Address A 2,�1,J;r���1 4 /fl�,�L 1 ...a��'1.... =� '1 r_.1,2,% �,r_/:��.k' Installer Addressd Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms.............................. ....... .....Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building ............................ No. of persons-----_--.._--_----------_- Showers ( ) — Cafeteria ( ) 41' Other fixtures ----------------------------------------------------- ----------------------------------------------------------------------------------------------- d W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity----------..gallons Length---------------- Width................ Diameter---------.------ Depth..-----_------. xDisposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet...__..:____-.-_--. Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by..............•- ......................................................... Date.---------•---------------------------- Test Pit No. I----------------minutes per inch Depth of "Pest Pit..--_---._----_---- Depth to ground water---------....--..-.--.-- (1, Test Pit No. 2................minutes per inch Depth of Test Pit............._-.--_- Depth to ground water........._-------------- ODescription of Soil-----�-~-�-��./�i>'J�--------•-•---------------------•-•---------------•--•-•-••---------•---------------...----....------------------------------------- x = -------•-------------------------------------------------- ----- ----------------_ ----•---------------------- ---------------- U ----------•----•-------•- ... '..'.-- `s"_�.�1,/ ,1/���r�°_ .-':3--------------------------------------------------------------------------------------------------------- `J . .................................................................... ........................................................................................................... ................... U Nature of Repairs or Alterations—Answer when applicable................................................................................................ --------------------------------------------- .........................................-----------------------------.....------------------------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beenlissued by the board of .ealth. SiV, ;� �—,/ ed...... --•---------•----------------------- D e � Application Approved BY L 1. Lam' -------------------------- ---- Date Application Disapproved for the following reasons:.......................... ----------------------------.........----------........---------------••-•----------- ...................................................... --•-------•------------•--------•-•-•------------•..---••----•--------------••-•--•-------•....----------•---- ----------------------------------- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH JIE>?1.1................oF..! .... . x1rdifiratr of f.11,11mViiaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (L')r by �Jf 1�A i'?J__lr'_L ....... � f iy Inst111er at s'-: �i�f f'1�� ..... �Z! ..d ' -frly/...l".._/,t has been installed in accordance with the provisions of Ar ' e XI of The State Sanitary Code as_described in the application for Disposal Works Construction Permit No.. �--- ---2_�.` .-__-_.._-. dated...-j .. . ..7 ........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE© AS A GUARANTEE THAT THE SYSTEM WILL UNCTION SAUSfACTORY. DATE � ------------------- Inspector. THE COMMONWEALTH OF MASSA HUSE TS I BOARD OF HEALT 1 No. �..... ! FEE I" G..Q...--•••- �i��u�:tti urk� C�uu�#r�tr#tuat �rrntt# Permission is hereby granted - 1=.. .2: ` / 1r '' to Construct( ) or Repair (i-)',an Individual Sewage Disposal System at No..... z�-- Street as shown on the application for Disposal Works Construction Pegnit --•••----........ Dated----` --- _ DATE. G ---- G Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS i) I ALL PIPE SPECIFIED AE PLOW PROFILE EXPRESSEDLINV DECIMAL FEET NOT ATIONS FEET AND INVERT INCHES.TIONS TOP OF FOUNDATION RAISE COVERS TO WITHIN SIX INCHES OF FINAL GRADE = 36.28+- ONE INSPECTION RISER FOR LEACHING GALLERY TO EL WITHIN 3 INCHES OF FINAL GRADE AS INSPECTION PORT. 36.00 D-BOX ALL PIPE TO BE MAX SCHEDULE 40 PVC 3" DROP AND TO PITCH AT FLOW LINE 33.00 1/6 in/FL MIN. 10' - 14 48" GAS!V' " . PRECAST` BAFELEF. 33.00 , DRYWELL 6 in Q �^ T r BOTTOM OF 34.20 STON 32.3E LEACHING GALLERY EXISTING 6 in STONE BASE 32.55 , BASE 32.25 GALLERY.. .. 33.25 30.25 5.00 Ft 1500 GALLON ;` ,, x (END v1EWY 7.Ft SEPTIC TANK II/ SEE DETAIL ON,REVERSE 10 ft SEPTIC I A K el 5 ft " 12.5' ft 6l 12 f t ,ADJUSTED .SEASONAL 9.3 HIGH GROUNDWATER co M D fT1 - r Y I AJ / m Z rn / \\ a _ �. 0 2 Z -10 y . 3 X � z / t a n� �R1. fTl �X m 0 0 0 / \ L'n rq ~ \y ym I-z _ z 3 0 —i co y O ck) z / \ MM Dt C ® (nf�r 0 Lo cn n M -,� r'N d o cn ❑ O CDs w / .F , —\-N z M / rn X � rmoxox / \ w m rn —� / \ w Cy2��crn M " \ rnra 9 / rn N /,. \ cnm�yo� U� < = o m7 ` . z�z��o r .sc� - f ..' .\.-�.�yl�.... - .1.+.:.vim.-.....---- -- �-�T-..a---"-"`.�=---�'+k,._ �w�• ..a.�-: -•......+�.'e.w�........:.....;.�...\\- -- - -- -_ ... _T� o,—�.•�'�C.. . ...,...�n:_. /( \ �rn m p : �O �r=n�o . N ` Z m ro \ rn�rn0rTl m \ \\ cnm�aOQrn �C3a3 . _co , y o a� am orn \ (p F-D / �� m m =f=TIDO� Z o�o� � m o� ®� �� mom_, 0lFq cl i cwn�ocn� rn p 3rn Z �7jZ Bn d M���o m mcjl rn q� 1 co��,y �\ 4�1w U3��0 U . i L0 S ��ZC'. ra \ o0r-or cn m y cz. c / M-uomm ~ L o o � O 0 G� -p w o I� N Ioo�r- O C c y O N p O m VJ y Fo w �rcl��1 7 Zmozn < - O s� oo�o� N rn o �13 m silo � r0D=Z Z �r o xo N y z Z m M 0 m < _ Ln p, g COM�o Z O �� z o�3mD crl Z O M y O Nay O y� U,�Z o m N fTl y z r .� � I . ovor� �_ .D r U7 c v Z 0 3N�IW <�ooj CD � Fl0 b z z o < ° o "'3" p 1� Z o N w 0 0 D D ZZ r O> rn m V J m z c ,��1'� y �u IP >❑ r 3 oR a o p C�0= MD M STREET ��mm z Z LOG OF TEST: JUNE 30. 2009 SOILTEST APPROVED SOIL EVALUATOR: DAVID D. COUGHANOWR. #461 DESIGN CALCULATIONS WITNESSED BY: DAVID STANTON. HEALTH DEPT. PERC NUMBER: 12615 DESIGN FLOW: 1 BEDROOMS X 110 GPD = 110 GPD SEPTIC TANK: 110 GPD X 2 DAYS = 220 GALLONS NO GROTUNDDWATE LENCOUNT ALD OUTWASH INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) TEST PIT DISTRIBUTION BOX: USE 3 OUTLET D-BOX. PERC AT 60 in - 2 MIN/INCH IN C SOILS SOIL ABSORBTION SYSTEM: A 24 Ft x 12.5 Ft, x 2 Ft:. LEACHING GALLERY CAN LEACH ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER Abot = ( 24 x 12.5 ) = 300 sf (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING Asdw = ( 24 + 24 + 12.5 + 12.5 ) x 2 = 146 sf 35.60 Atot = 446 of 0-6 Ap LOAMY SAND 10 YR 3/3 NONE FRIABLE Vt 0.74 x 446 = 330.04 GPD 33.63 6-26 B LOAMY SAND 10 YR 4/4 NONE LOOSE USE A 24 f t x 12.5 Ft x 2 f t GALLERY. Vt = 330.04 GPD > 110 GPD REOUIRED 24.80 1 26-132 C MEDIUM SAND 10 YR 5/4 NONE LOOSE TEST PIT 2 NO GROTUNDDWATER EMATERIAL: NCOUNTER LD OUTWASH L EA CHI NG GA L L ER Y 2 MIN/INCH IN C SOILS USE SHOREY PRECAST 500 GALLON NOT TO LEACHING DRYWELL (H-10 LOADING) SCALE 1500 GALLON SEPTIC TANK ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER DIMENSIONS AND DETAIL NOT TO 36.20 (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING CONSTRUCTION DETAIL USE SHOREY ST-1500-H-10 SCALE 0-B Ap LOAMY SAND 10 YR 3/3 NONE FRIABLE DRYWELL UNIT STONE 33.63 B-30 B LOAMY SAND 10 YR 4/4 NONE LOOSE 24.0 ft 1 in 30-126 C MEDIUM SAND 10 YR 6/4 NONE LOOSE m TAPER Q 24.80 m 4J GROUNDWATER ADJUSTMENT DISTRIBUTION BOX � IE:�:]L�] �4 N U 5 {t- N o 8 In EXISTING GROUNDWATER LEVEL DIMENSIONS AND DETAIL USE SHOREY D8-3 H-10 m, BASED ON TOWN OF BARNSTABLE m GIS DEPARTMENT RECORDS. 3.5 ft 8.5 ft E INDICATED GW 7.00 Nor TO Y7MIN 24.0 ftINDEX WELL M1W-29 SCALE le f k ZONE ~.READINGDATE> M=AY 2009 FROM READING', - . 4"'�. c TANK TO N. ADJU'STMENT : 2 3`�, c� SAS 500 GALLON DRYWELL D D U S T E D G W 9 3 :r ,; O DIMENSIONS AND DETAIL INLET CENTER OUTLET END COVER END 6 In STONE BASE USE H-10 UNIT INSTALL ONE INSPECTION ..:,.r .. ..:,,. ..,,,,.0.... ...... .......... k RISER TO WITHIN THREE 3 IN DROP /�,„t k *f 15 ��• CROSS SECTION VIEW INCHES OF FINAL GRADE —► /l FLOW LINE _ AND INDICATE LOCATION FROM � BUILDING a• ° '' ` ' t ON AS-BUILT PLAN 10 to = 14 TO D-BOX ` 48 { LIQUID GAS f 33 LEVEL BAFFLE oc N 0 T�E S C oc o co oo�oo In 00000000000 000 D INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE STARTING WORK. o0 0 0 i� CROSS SECTION VIEW 2) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. le21n 3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REOUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15). CROSS SECTION VIEW 4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES SEWAGE DISPOSAL SYSTEM PLAN BEFORE EXCAVATING FOR SYSTEM. 2 In PEASTONE to o PEASTONE 5) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST IN PLACE. o TO SERVE EXISTING DWELLING 6) ECO-TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES 28 �4,,, ro zEFFEECTIVE2AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK. in -112'^ � DEPTH In DAVID P. HEATHERMAN 7) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL 25 MILNE ROAD OSTERVILLE. MA STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH 46 in 58 In 46 in SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN SETTLING. 150 in EEO—TECH ENVIRONMENTAL B) SEPARATION OF TEES IN SEPTIC TANK SHALL BE NO LESS THAN LIOUID DEPTH. INSTALLER MAY O BF TH FABRIC E 2 ,� PEAS TONE SGEOTEPEC FIEQ. 43 TRIANGLE CIRCLE SANDWICH MA 02563 ETE-3178 I JUNE 30, 2009 1212